Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall
Carolina Maria Helena Hilton1, Magnus Balslev Avnstorp1
- 1Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark
Abstract
Keywords: Hatchet flap, thoracic skin defect, malignant melanoma, reconstruction Authors: Carolina Maria Helena Hilton, MD, Magnus Balslev Avnstorp, MD. Institution: Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark Abstract A 73-year-old man was diagnosed with a malignant melanoma on the left anterior chest wall. According to guidelines he was scheduled for re-excision in 20 mm and sentinel node procedure. The defect following re-excision was too large for primary closure. A Hatchet flap was designed, covering the defect, with a cosmetic and functionally acceptable result. Patient medical history A 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure. Before and After Patient examination The skin examination showed a cicatrice on the left chest wall, close to the neck, measuring around 30 mm, where skin mobility was not sufficient for direct closure if excised with a 20 mm margin. A lymph node scintigraphy showed two sentinel nodes in the left axilla. The patient was taking acetylsalicylic acid which was continued according to Danish guidelines (from “Dansk selskab for Trombose og Haemostase” (the Danish society of Thrombosis and Hemostasis)) . Pre-operative considerations Direct closure would probably result in reduced neck mobility or at least uncomfortable
BeforeAfterA 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure.
The cicatrice was marked, and a surgical margin of 20 mm was drawn.
The Hatchet flap was designed with the back-cut area placed as shown as not to displace the nipple. The flap was drawn x 2-3 times the width of the defect size.
2
The tumor was excised with a 20 mm margin to the muscular fascia. Hereafter the crescent-formed flap inscison was made.
3
The flap was raised in the plane above the muscle fascia, frequently testing if sufficient mobility was achieved while trying to minimize the length of the back-cut. While raising the flap perforators were spared.
4
5
Due to the size of the surgical area and the fact that the patient was taking acetylsalicylic acid a glove-drain was placed, and the patient was given a single dose intravenous Cefuroxime 1,5 g. The flap was sutured with a monofilament absorbable suture 3-0 (Maxon, Medtronic, USA) in the subcutaneous fascia, 3-0 absorbable uncolored polyfilament dermal inverted sutures and 3-0 absorbable monofilament intracutaneously (and non-absorbable colored monofilament suture for the drain).
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At three months postoperatively, the patient was satisfied with the cosmetic result and had no physical complaints.
7
The patient stayed overnight in hospital due to the applied glove drain. The patient was discharged the following day after removal of the drain. No further antibiotic treatment was required. The patient was instructed to avoid compression of the flap and advised not to engage in strenuous physical activities, such as sports or housework for 14 days. Paracetamol as needed (1 g, maximum four times daily) was prescribed for analgesia.
The patient was seen in the outpatient clinic eight days later for histology results. There were no metastases to the sentinel nodes. Therefore, he was classified as clinical stage 1B. According to guidelines the patient will be monitored clinically yearly for five years including a final control of the flap three months after surgery.
How to cite this article
Carolina Maria Helena Hilton, Magnus Balslev Avnstorp. Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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